Management of

mandibular fractures
Part 2

Presented by: Fawaz Baig

Moderated by: Dr. Supriya Joshi
 Contents
General principles of management of mandibular

fractures

Management of fractures involving the body of the

mandible:

Symphysis

Parasymphysis

Management of fractures involving the angle of the

mandible
Principles of management

Reduction

Fixation

Immobilization
 Modalities for management
Methods of reduction:
Closed

Open

Methods of fixation:
Internal/External

Direct/Indirect

Immobilization:
Short term/Long term
 Closed reduction-advantages
Inexpensive
Minimal equipment required
Technically easy
Usually an outpatient procedure-no operating room required
Not surgically invasive-minimal tissue damage
Easily available & convenient
Short procedure
Gives occlusion leeway to adjust
No foreign body left in situ-no need for its retrieval
Secondary bone healing allows bridging of small bony gaps-
very useful in communiated fractures
Closed reduction-disadvantages
Reduction/immobilization not complete
Inconvenience and non-compliance (IMF)
Difficult nutrition
Oral hygiene suffers
MPDS/TMJ dysfunction
Muscular atrophy/weakness
Myo-fibrosis
Weight loss
Loss of bite force
Trismus/decreased range of motion
Risk of needle stick injuries to operators/patient
 Open reduction-advantages
Accurate reduction and stable immobilization-primary bone
healing

Normal nutrition in a matter of days

Early return to normal jaw function

Avoidance of airway problems

Oral hygiene can be maintained

No IMF no occupational inconvenience

Good patient compliance-decreased discomfort

Less myoatrophy/TMJ disorders/MPDS

Less trismus/derangement of jaw movements

 Open reduction-disadvantages
Need for surgically invasive techniques

Risk of damage to anatomic structures

Need for operating room and prolonged anaesthesia

Success depends on technical expertise

Expensive equipment/materials required

No leeway for occlusion to adjust

Scarring

No bridging of small bone defects

Might lead to loss of multiple, small bone fragments

Might require secondary procedure to remove hardware

 Methods of fixation
Fixation devices may be placed directly adjacent to the

fracture fragments into the bone (direct skeletal) or on the

teeth/denture bearing area (indirect skeletal).

Further, they may be placed completely within the soft

tissues (internal) or placed outside the tissues but inserted

into the bone percutaneously (external)

 Methods of fixation ..contd
Indirect skeletal fixation methods involve different interdental

wiring techniques, arch bars and splints that aim at restoring

the occlusion by manipulating the alveolar process adjacent

to the fracture site and thus achieving closed reduction and

fixation

Whatever the method used, the purpose is to hold the

reduced fracture fragments in their normal anatomical

relationship, to prevent their further displacement and to

achieve proper, stable approximation

 Indirect skeletal fixation
The different wiring techniques used are:
Direct interdental wiring
Interdental eyelet wiring (Ivy loop method)
Button wiring
Continuous/multiple loop wiring (Col. Stouts method/Obwegeser
method)
The different splinting techniques are:
Cap splints metal/acrylic
Gunning-type splints
Partial dentures
Also involves use of arch bars
Precast commercially available arch bars
Customized arch bars
Acrylated arch bars
Directly bonded arch bars
Essential to the indirect skeletal fixation methods is
intermaxillary fixation with or without skeletal suspension
Risdons direct interdental wiring
Ivy loop method
Ivy loop method - IMF
Stouts Method
Tackling the lone-standing tooth
Button intermaxillary fixation
Types of arch bars Rigid IMF

Elastic IMF IMF using screws

Securing the Arch bar
Gunning type acrylic splints
 Circum-
mandibular wiring
 Circum-mandibular wiring
intra-oral view

Circum-mandibular wiring
Control of inferior border
Acrylic splint stabilized using Circum-
mandibular wiring
 Direct skeletal fixation
Consists of External and Internal methods
External fixation:
Pin fixation
Bone clamps

Internal fixation:
Transosseous wiring (wire osteosynthesis)
Bone plates:
Compression plating systems
Mini plate systems
Intramedullary pinning
Titanium mesh implants
Circumferential straps
 Immobilization
This phase lasts for 4-6 weeks for mandibular fractures

The fixation devices are retained till bony union takes place

The duration of immobilization depends on the extent and

type of the fracture, degree of injury, patient age and general

medical status

May be prolonged in cases of complications

If immobilization is not complete, callus maturation is

affected and may result in malunion/fibrous union/nonunion

of the fracture fragments

It also may result in prolonged pain/infection

 Management of body fractures
Part of the mandible anterior to the angle

2 parts can be defined

Symphysis between the mental foramena on either side

Parasymphysis at or posterior to the mental foramena

Body fractures are usually a/w extension through the

alveolar process and are thus most often compound

Symphysis # may be a/w bilateral condylar fractures or

impaction of the condyle(s) into the middle cranial fossa

Parasymphysis # may be a/w contralateral condyle

fracture, usually at the neck
 Closed reduction of body fractures
Indications:

Nondisplaced favorable fractures with no/minimal occlusal

derangement

Grossly communiated fractures

Fractures exposed by significant loss of soft tissues

Edentulous mandibular fractures

Mandibular fractures in growing children with developing dentition

Dento-alvelolar/dental fractures if present should be treated

concomitantly
Closed reduction of body fractures ..contd
Most commonly used methods are:

Erich arch bars/Ivy loops for dentulous mandibles

Circummandibular wiring/Cap splints in children

Gunning type acrylic splints for edentulous mandibles

Usually, immobilization upto 4-6 weeks will be needed to

ensure healing of the fracture in correct occlusal relationships.

Soft diet for the duration and maintenance of oral hygiene are

essential
External direct skeletal fixation
This is most commonly accomplished by using External pin

fixation/Biphasic pin fixation

Was used in cases where compound, communiated and

infected jaw fractures were present and required remote

immobilization

Useful in cases with b/l edentulous posterior fragments and

where bone grafts need to be placed

It also finds application in simultaneous treatment of middle

third fractures
External direct skeletal fixation
..contd
It eliminates the need for IMF in most cases and as the

apparatus is extra-oral, oral hygiene and feeding is not

affected

However, cumbersomeness of the appliance, difficulty in

sleeping, patient non-compliance, need for frequent

tightening of the universal joint, difficulty in carrying out

chores like shaving, washing and the scarring associated with

it have led it out of favor

Modern antibiotics and surgical methods have almost

eliminated the use of pin fixation

 External Pin Fixation
General principle is the use of 2 pins, joined to each other by a

transverse rod and 2 universal joints, inserted into the principle

anterior and posterior fragments of the jaw.

Each pin assembly is then united by a further rod/rods held by

universal joints attached to the transverse bars

Jaw immobilization if required is done by use of a box frame, a

Levant frame, a halo head frame or even a POP head cap

 External Pin Fixation contd
Generally, the pins are 7 cm long and 3 cm wide, to overcome

swelling due to edema and provide adequate strength

Pins are constructed of inert metals to prevent local osteitis and

inserted into the bone using hand power drills

Types of pins:Clouston-Walker pins, East Grinstead type,

MacGregor pins, Moule pins, Toller pins

Universal joints are usually made of insulating materials like

Tufnol
 External Pin Fixation contd
Operative technique:

Landmarks are located and marked, along with the position

and angulation of the fracture

After thorough preparation of the skin, the posterior pins are

placed first app. 1 cm from the angle through a small stab

incision at the level of the inferior border. Blunt dissection if

done down to the bone

Before placing the pins, pilot hole is made to prevent

splitting
 External Pin Fixation contd
Operative technique .. contd

The drilling is done through a metal sleeve at right angles to

the cortex, and once it is engaged, the angulation is
changed to 70 till the inner cortex is penetrated

The anterior pins are located such that the spacing and
angulation is sufficient to prevent overlapping of the pins in
the bone and not be too far apart while converging towards
the 1st pin

The pins are then screwed into place with app 1-2 mm
projection beyond the inner cortex and the apparatus
assembled
Using a metal sleeve for drilling
 External Pin Fixation contd
Complications:

Anesthesia/paraesthesia of the lip due to Inf. alv. N damage

Involvement of fracture site/surrounding hematoma by infection

Widening of oblique fracture lines and displacement of lingual

cortex

Over penetration/splitting of the bone

Damage to adjacent structures due to improper location of stab

incision or slippage of drill/pin beneath the inferior border

Loosening of the pins due to functional movements of the

jaw/striking of apparatus on external objects - failure of
immobilization malunion/nonunion/infection

Acute infection around the pins removal of pins

External Pin Fixation assembly
Morris appliance
 Open reduction - Indications
Compound fractures with contamination by oral fluids
Displaced and non favorable fractures inadequate reduction
and fixation by closed methods due to muscle pull continued
displacement
When early post-operative mobilization is required due to
concomitant condylar fractures
Multiple mandibular fractures
Pan facial fractures the mandible needs to be fixed rigidly to
form a base
When IMF is absolutely contraindicated mentally challenged,
epileptics, asthmatics, panic attacks, alcoholics, drug abusers,
pregnancy, etc.
When patient does not accept IMF due to occupational needs
When a/w loss of bone segments and bone grafts are required
 Surgical access
Can be intraoral/extraoral. In most cases, intraoral approach is

used to avoid external scarring/damage to marginal mandibular n.

However, intraoral approach provides slightly limited access and in

cases where gross displacement is present, extra-oral approach

may be more suitable

Thus, when existing facial lacerations are such that adequate

access can be obtained through them, extraoral approach is used

The choice of approach is thus based on the extent of fractures,

location of extraoral lacerations and presence of infection

Surgical approach requires general anaesthesia, IV antibiotic

course and hemostasis control using local agents and

electrocautery.
 Intraoral approach to symphysis and
parasymphysis
Provides adequate access and scar is hidden and minimal

Infiltration with L.A. + adrenaline is done for local hemostasis

The length of the incision should be enough to allow adequate

exposure and access without over-retraction. Usually from

midline to just anterior to the 1st molar

This incision should lie atleast 1 cm onto the lip and curve

towards the attached gingiva in the region of the

premolar/molar

Incision is initially made perpendicular through the mucosa

and 1 mm into the mentalis muscle layer

 Intraoral approach to symphysis and
parasymphysis contd
Then, the angulation is changed so that it is directed perpendicular to
the bone and a full thickness incision made through muscle and
periosteum

This allows for good closure with adequate muscle cover to prevent
dehiscence, plate exposure and loss of vestibular depth

After the incision, subperiosteal dissection is done to expose the

fracture site(s) upto the inferior border or 1 mm beyond

Mental nerve is carefully located and preserved

The fracture ends are curetted to remove fibrous and granulation

tissue

Closure is done in single layer with deep bites through muscle on

either side
Intraoral approach - body and angle
After administration of local hemostatic, cheek is retracted

laterally and mucosa is incised to the bone 5 mm below the

mucogingival junction keeping the blade perpendicular to the

bone.

Posteriorly, the incision is carried along the external oblique

ridge taking care not to go too high to avoid exposing the

buccal pad of fat.

Anteriorly, the incision is made long enough to expose the

fracture site adequately and allow access without over-

retraction
Intraoral approach - body and angle
The anterior surface of the ramus can then be exposed by

stripping the buccinator and temporalis tendon and retracted

using a notched, angled retractor.

Once the coronoid is exposed, a curved Kocher clamp is

applied

The masseter is then elevated using periosteal retractors till

below the inferior border and toe-down angled retractors

placed.

Anteriorly, the mental nerve is carefully located and

preserved
Extra-oral approach - symphysis
Existing lacerations if suitable are used and can be extended if req

For symphysis fractures, incision is marked directly over the

inferior border within a skin crease

Infiltration with local hemostatic is done and incision made using a

#15 blade through skin and subcutanous tissue down to the bone

Alternatively, electrocautery can be used after initial skin incision

to deepen it to the bone. Bipolar is used for hemostasis

The fracture site is exposed by subperiosteal dissection from 1 mm

beyond the inf border till the subapical region

Closure is done in 2 layers, using absorbable sutures for muscle

and subcutaneous layers and nonresorbable sutures for skin
 Submandibular approach
Existing lacerations if suitable can be used and extended as req

Approach is through submandibular incision (Risdon 1934) and useful

in exposing the body, angle and ramus

Incision is marked 1-2 cm below the inferior border within a skin

crease to avoid damage to marginal mandibular n which lies just

below the deep cervical fascia within 1 cm above/below the inferior

border from angle to ant border of masseter. It supplies the

depressors of the lower lip.

Infiltration with local hemostatic is done and 4-5 long incision made

using a #15 blade through skin, subcutanous tissue and platysma.

Submandibular approach ..contd
Electric nerve stimulators are useful in localising the course of the

nerve and thus avoid it.

The dissection to the bone is carried out through the deep cervical

fascia with careful use of the nerve stimulator. The nerve fibres are

retracted superiorly and blunt dissection used to expose the pterygo-

masseteric sling.

The capsule of the submandibular gland below and lower pole of

parotid gland above may be encountered. Care is taken to prevent

disruption of these sialoceles/salivary fistulae

This sling is tough and cutting through it is made easier by using

electrocautery down to the bone

 Submandibular approach ..contd
Subperiosteal dissection is then done to expose the angle, body and
ramus and thus, the fracture site

If facial vessels cannot be retracted successfully, they may be ligated

and cut

Exposure can be increased and closure enhanced by dissecting the

medial pterygoid and stylomandibular ligament from the inferior and
posterior border

The ends of the fracture segments are then curetted to remove

fibrous/granulation tissue

Closure is done in multiple layers using resorbable sutures for the

muscle layers and subcutanous/platysma layer and nonresorbable for
skin
 Retromandibular approach
Hinds and Girotti (1967)

Most useful in gaining superior access to the ramus and

subcondylar region, but can also be used in angle fractures

Originally described as a modification of the Risdon approach

with the incision placed 3 cm above it and curving behind the

angle of the mandible.

Alternatively, it is also decribed as a 2-3 cm long linear

incision along the posterior border of the ramus of the

mandible starting just below the lobe of the ear

 Wire osteosynthesis
Refers to the direct skeletal fixation of 2 or more bone
fragments with the aid of wire ligatures pulled through
previously drilled holes
Direct wiring keeps the fragments in anatomic alignment, but
additional immobilization using splints/IMF is often necessary
Useful in the control of
The edentulous posterior fragment
Edentulous mandibular fractures
Grossly communiated fractures
Lower border in the presence of multiple mandibular fractures
with conventional methods securing the superior border
Where IMF is contraindicated/not accepted by patient
Fractures of the ramus
 Wire osteosynthesis ..contd
Technique:
Holes are drilled in the bone ends 6mm distant on either side of
the fracture line
Then, 0.45 mm D soft stainless steel wire is passed through the
holes and across the fracture line
After accurate reduction, the free ends of the wire are twisted
together tightly, cut off short and the cut end tucked into the
nearest drill hole
Various types of ligature techniques are recommended:
Simple ligature secure small bone fragments
Simple ligature + figure of 8 transverse/oblique fractures
Double ligature one above and one below the mandibular n
Can be performed via an intraoral or extraoral approach
After the foray of miniplates, this technique is slowly falling out of
use
Technique for simple
ligature + Figure of 8
 Compression plating systems
Goal Absolute stability
Primary bone healing?
Generation of preload
Inter-fragment friction
Maximum compressive forces upto 300 kPa/cm2
Effect is stabilization of fracture, minimizing inter osseous gap and
reduced chance of infection/nonunion
Ideal location is at region of max tension superior border but due
to presence of tooth root and inf alv bundle, this is not possible
Thus the plate is inserted at the lower border, but this fails to control
the superior border fanning tension banding req
Disadvantages bulky, more chance of plate exposure, palpable -
patient dissatisfaction
2 types dynamic compression plates, eccentric dynamic
compression plates
 Monocortical miniplate osteosynthesis
Basic principle is to fix plates along the Champys lines of

osteosynthesis

The Champys lines run from either sides of the external oblique

ridge forwards, above the level of the mandibular canal to just below

and ahead of the mental foramen, where it splits, going above at the

subapical level and below just above the inferior border

Plating along these lines will eliminate torsional forces which tend to

open up the fracture sites at the superior border

Monocortical miniplate osteosynthesis..contd
Technique:

The fracture sites are exposed as described before

Plate of suitable size and thickness is selected (usually 2.0mm

4-hole with gap for inf border and 2.0 mm 2-hole with gap for

subapical)

Plate is bent using plate benders to conform with the

curvature of the bone

Fracture is reduced and held in place by bridle wires and IMF

Holes of conforming size are drilled through the outer cortex

perpendicular to the bone and screws are placed

Monocortical miniplate osteosynthesis..contd
Advantages:
Reduced size smaller incision & minimal soft tissue dissection
Can be easily placed intra-orally
Less likely to be palpable less likely to need removal
Uses monocortical screws less likely to damage adjacent structures
Can be easily contoured in 3 dimensions
Disadvantages
Smaller size less rigid torsional movements/plate fracture
Limited use in communiated fractures
Required longer period of reduced masticatory function post
operatively (soft diet)
Clinical applications:
Symphysis # - 2 plates at subapical and inferior border
Parasymphysis # - single plate at subapical region
Angle # - single plate at external oblique ridge
 External oblique ridge

Fixation of angle fracture intra-oral approach

ORIF of angle # in edentulous
mandible
 Lag screw fixation
Brons and Boering (1970)

Acts by gaining purchase into the cortex of most distant

fragment while fitting passively in the proximal fragment

Possible to achieve 2000 4000 N of compressive force

Indications:

Symphysis fractures strong cortical bone excellent

buttress

Angle fractures

Long sagittal fractures of the body

Fixation of bone grafts in areas of bone loss

Lag screw fixation of symphysis #
 Intra-medullary pinning
Major (1938) McDowell use in maxillofacial fractures

2mm K-Wires are used

Useful in emergency, immediate stabilization of a fractured

mandible

Versatile, can be applied in any part of the mandible

However, stability provided is not adequate for

fixation/immobilization
Application of
K-wires